Wiki E.M level

[ny2scgirl]

My provider always charges a 99214 for ADD follow ups even if he didn't change the medication. I believe this is a level two. Thoughts?

Reason for Appointment 1. ADD

History of Present Illness Advanced Care Planning: Here for sch'd apt Has been doing well in school, all A's this year Seems to have good appetite and reportedly sleeps well.

Vital Signs Temp: 97.8 F, HR: 70 beats per min, RR: 18 breaths per min, O2 sat %: 99, BP: 108/70 mm Hg, Wt: 70.6 lbs, Wt %: 12.59 %, Ht: 57 in, Ht %: 35.21 %, BMI: 15.28 Index, BMI %: 9.35 %, Wt-kg: 32.02 kg, Ht-cm: 144.78 cm With mom.

Examination General Examination: GENERAL APPEARANCE: alert, well hydrated, in no distress . HEAD: normocephalic, atraumatic. EYES: BOTH EYES, eyelids normal, conjunctivae normal, sclera non-icteric. HEART: regular rate and rhythm, S1, S2 normal, no murmurs, rubs, gallops. LUNGS: clear to auscultation bilaterally. CHEST: normal shape and expansion.

Assessments 1. ADHD (attention deficit hyperactivity disorder), combined type - F90.2

Treatment 1. ADHD (attention deficit hyperactivity disorder), combined type Refill Concerta Tablet Extended Release, 54 MG, 1 tablet in the morning, Orally, Once a day, 30 days, 30 Tablet, Refills 0 Notes: Attention Deficit Hyperactivity Disorder (ADHD) in Children: Care Instructions material was published Clinical Notes: doing well on current dose

Follow Up 4 Months (Reason: add)

 

[amyjph]

The "always charges a 992_ _" thing is generally going to be a red flag. The level will always be dependent on the documentation.
If this is office/outpatient later than 2021, and no time is documented, and what you have above is the whole note:
1. Low/Minimal/Moderate = 99213*. I agree with you it is not level 4.

I would have a talk with my provider if they "always" charge the same level all the time to every patient.

*edited to fix EM level and adjust from 99212 to 99213.

 

[carlystur]

I'm confused as to how you got level 2 from a low problem, which is level 3, and moderate management, which is level 4. That would make it level 3, not 2.

As ADHD is a problem that does not go away (a chronic problem), but seems stable as the patient is doing well and no other documentation to suggest otherwise, would make this a stable chronic problem with moderate level management - 99213.

EDIT: I do, however, agree that any provider who "always" charges a specific level for any and/or all patient visits is a problem and the provider needs to be educated on that.

 

[amyjph]

I'm confused as to how you got level 2 from a low problem, which is level 3, and moderate management, which is level 4. That would make it level 3, not 2.

As ADHD is a problem that does not go away (a chronic problem), but seems stable as the patient is doing well and no other documentation to suggest otherwise, would make this a stable chronic problem with moderate level management - 99213.

EDIT: I do, however, agree that any provider who "always" charges a specific level for any and/or all patient visits is a problem and the provider needs to be educated on that.

You are correct, sorry for the bad info, I was reading and typing fast. I will edit my post to adjust.